It is not as strict as the leaked version but would still drastically limit what benefits they could use without risking green cards or permanent residency status.

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The Trump administration released a rule on Wednesday that would make it harder for legal immigrants to obtain green cards or permanent residency status if they have used certain government benefits.

Unlike the leaked version, the final rule exempts health-insurance subsidies and the Children's Health Insurance program but not Medicaid.

The rule is opposed by groups representing not only immigrants but mayors, patients, low-income communities and health-care interests.

It is not final until after a 60-day public comment period.

After more than a year of discussion, the Trump administration released its final rule on Wednesday to limit what public aid legal immigrants could receive without penalty.

The rule would make it harder for legal immigrants to obtain green cards or permanent residency status if they have used certain government benefits, including Medicaid, food stamps and housing subsidies. It will open up a 60-day public comment period.

The final rule is not as strict as a leaked version that was released earlier this year. That version included health insurance subsidies and participation in the Children’s Health Insurance Program as penalties for green-card applicants.

Still, the rule is expected to receive harsh pushback from advocates for immigrants, patients, low-income communities and health-care organizations.

"Conservatives say they want immigrants to ‘follow the rules’ of our nation. These families have done just that. Yet, this new rule continues the rewriting of core American values -- from a country that welcomes hard-working people who want to improve their lives and contribute to our nation -- to one that takes the bootstraps away from vulnerable families and doesn’t think twice in separating children from their parents."

Members of the U.S. Conference of Mayors (USCM) -- a bipartisan group representing the nation’s mayors -- unanimously voted to oppose the rule in June.

"This proposal will compromise children’s health, nutrition and development; impact access to health care for legal immigrants and citizens alike; reduce housing options; and negatively affect our local economies," said Steven Benjamin, mayor of Columbia, S.C., and USCM president, in a statement in September. "Make no mistake: The consequences will be dire and will force families to choose between the things they need and the people they love."

According to a report released last month by the New England Journal of Medicine, 19 percent of noncitizen adults use Medicaid, and 38 percent of their children are either on Medicaid or CHIP.

Health and human services experts say there is already anecdotal evidence that the proposed rule has had a "chilling effect," leading some immigrants to drop or forgo health coverage. The Center for Law and Social Policy conducted a report last year, finding that since President Trump took the White House, there has been an uptick in missed doctor's appointments among immigrants. Even though the final rule exempts health-care subsidies and CHIP, some legal immigrants may continue to avoid them out of confusion or fear, which could have negative ripple effects on the health-care market as a whole.

"Let’s be clear, all Americans are impacted when families are too afraid to seek treatment for their medical conditions -- for example costs go up for everyone when people delay receiving needed health care," said Isai.

The marketplace has struggled to attract younger, healthier populations, which has contributed to rising premiums. If more legal immigrants go uninsured, they could exacerbate that issue.

"We want kids to get vaccinations. We want people to have access to health care. When people don’t have that access, it impacts us all. It creates potential public health risks," says Emily Piper, Minnesota human services commissioner.

Governors who have come out against the rule, which include Democrats and Massachusetts Republican Gov. Charlie Baker, say they are working to reduce that confusion and fear.

"Right now the state government is working diligently to reduce confusion by providing accurate, reliable information to the families we serve," says Casey Katims, director of federal and interstate affairs for Washington Gov. Jay Inslee’s office. "The governor has instructed state health and social services agencies to thoroughly analyze and submit comments on the damaging impacts it will have on Washington’s children and families."